Monday, March 23, 2009

The Insurance Company Giveth, the Insurance Company Taketh Away

As you know, being in ART-limbo has been driving me steadily insane. Last week, J and I decided to buy a little piece of sanity—we are going start paying out-of-pocket for at least some of the drugs that might (emphasis *might*) kick-start J’s sperm production. We figure that even if insurance eventually denies us coverage, we would probably pay for a couple of months of treatment, just to see if it was going to do any good. So we decided to pay for a few weeks while we waited to hear back on our most recent appeal.

Last Wednesday I faxed in J’s prescriptions to Schraft’s (the cheapest specialty pharmacy out there), along with a note saying that he would call to work out ordering and delivery. The next morning, I got a call from Schraft’s with a question for the doctor (they assumed that I was the nurse). Once I gave them the doctor information, I also gave them J’s information—phone numbers, e-mail, date of birth, etc. When she asked about insurance I told her not to worry about it. “We’re in a protracted battle with the insurance company right now, so we don’t have any coverage,” I explained. She suggested that I give her the information anyway, just so his files would be complete.

That night, J picked me up at the train station with “good news.” His prescriptions were covered! “Not possible,” I said. Our most recent appeal—the previous one having been rejected by the asshole HMO because we had the wrong pre-auth number on it—was only a day old.

“That’s what I told them,” he said, “but they told me it had gone through and I owed a $50 copay.”

“So you filled the whole thing? All three months?” I asked, incredulous.

“Yup.” He grinned. “They actually called back to tell me it was going to be a $50 copay per month. I was like, ‘okay!’”

“I don’t believe it,” I said, “They’re gonna call back and say it was a mistake. Tonight.”

“Probably,” he agreed.

We went into the house and I went back into the bedroom to change my clothes. The phone rang. Our caller ID—which we’ve never been able to take off of “audio”—announced “Call from . . . Schrafts.” We looked at each other. “Well, it was a nice 15 minutes,” I offered.

From what J was saying on the phone, it was obvious what was happening. “Not covered? . . . We’ve reached our ‘cap’? . . . What exactly does that mean?” After a minute, he pulled out his credit card and ordered a three-week supply. We both knew that there was no “cap” to our coverage; we just weren’t covered. But whatever.

And in a normal world, that would be that. But this was no normal world. Because 15 minutes later the phone rang again. “Call from . . . Schrafts,” announced our caller ID in its creepy computer monotone.

“What the fuck?” I muttered, handing the phone off to him.

A minute later, he was off the phone again, total confusion on his face. “That was the pharmacist. She was calling to tell me that the person who called earlier was wrong and we haven’t exceeded our cap.”

“So we’re covered?”

“That’s what they say.”

“And you filled the entire thing?”


We waited all evening for the call that never came. The next day the drugs were delivered to our RE. Today J picked them up.

I don’t think Schraft’s come after us for this when our HMO realizes its mistake, can they? We were totally up front with them about this.

Score one for the little guy. (Not that J’s little, or anything.)


Darya said...

That's great! You guys deserve something good out of this. This shit sucks bad enough without having to worry about all of this extra stuff.

Pepper said...

Sweet! I sometimes wonder how often the "answers" we get would change depending on which person we asked. Probably also has something to do with a full moon and high tide, but it sure is nice when it works in your favor.

Io said...

Dude. Most excellent. I hope it stays on the good side and there are no more calls!

one-hit_wonder said...

How odd and annoying, but good in the end!

Lea said...

That totally rocks! Just goes to show how every little thing is such a rollercoaster! Dang. I'm so glad you get to move forward.

Ally said...

Yay! Take the drugs and run, friend! :)

Shinejil said...

YES! Finally a break for you and J! You so, so deserve this little bit of help.

Though your story is an excellent example of everything that's wrong with our current system (the insecurity, the lack of coverage, the expensive and timely back and forth).

Now, I'm crossing my fingers that the meds help.

Nikki said...

Insurance companies suck! I feel like they conspire against us all the time! :-)

Awesome that you got covered and got all the meds! Yay!

annacyclopedia said...

It's great that it worked out, but sheesh! What a pain the butt! Hope this represents the turning of the tide to an era of incessant good news for both of you.

Malloryn said...

Oi, I'm glad that it worked out for you guys in the end! I hope that you don't hear from them again.

Peeveme said...

Weird. Who knows for sure what the truth is (covered/not covered)? Just goes to show you what a mess our health care system and the insurance industries are.

Me said...


Lisa said...

Well, so far so good!! We're in an insurance fight still, too, so I feel your pain....

Good Egg Hunting said...

Ugh. I wish every one of us got an infertility assistant along with our diagnoses, to handle stuff like this. IF is hard enough on its own. But I'm glad this battle ended in your favor -- hope it stays that way.

Jaded Girl said...

yup, i think it was one big conspiracy to drive you both crazy.
in all serousness - i am glad you both got this lucky break.

Ms. J said...

I am anxiously awaiting the next chapter to this saga . . . IF/WHEN they figure out they could still get money outta ya?!

kate said...

Awesome! Little perks like this are great... I do know that when I was dealing with a change in plans that I asked the pharmacist to just let me pay out of pocket so that there wouldn't be any insurance mess, but the pharmacist insisted on filing under my old plan. I then got a nasty letter from old plan (even though new plan was ALSO under the same company, just different division) insisting that I pay them back the seventy-whatever dollars.

Regardless, if they've talked to the insurance group and the insurance group said they'd cover it, then COOL. You're totally off the hook. If they try to come back later and say that you owe them something, I'd tell them to fuck off, that they get one do-over which they've already communicated.

Rebeccah said...

I'm loving this! Insurance companies are the worst.